Revision Rates After Total Ankle Replacement: A Comparison of Clinical Studies and Arthroplasty Registers

Results of Total Ankle Arthroplasty Versus Ankle Arthrodesis

No differences have been found between total ankle arthroplasty (TAA) and ankle arthrodesis (AA) with respect to patient-reported outcome measures (PROMs), although both interventions were shown to improve PROMs with respect to the preoperative situation. That is, both interventions (AA and TAA) were effective in improving preoperative symptoms. On the other hand, 2-year complication rates were higher after AA (27%) than after TAA (16%); however, infection rates were similar (4%). The published revision rate after AA is 16% versus 11% after TAA. In short, TAA and AA appear to offer the same PROMs, but TAA has a lower rate of complications (except for infection) and revisions.

Revision of total ankle arthroplasty: Survival and medium-term functional results

BACKGROUND

The objective of this study was to analyze the results and survivorship of total ankle arthroplasty (TAA) revision surgery with standard (Salto Talaris®) or revision (Salto Talaris XT®) implants.

METHODS

Between January 2005 and December 2017, all patients undergoing TAA revision at our hospital were included. Indications for revision, type of surgery performed, improvement in function assessed with the AOFAS score, occurrence of complications and implant survival at last follow-up were analyzed.

RESULTS

In the end, 25 TAA patients who had undergone revision (11 unipolar, 14 bipolar) were included. The mean follow-up time was 5.1 ± 1.9 years. At the last follow-up, function was improved compared to the preoperative AOFAS score (51.3 ± 17.5 vs. 83.5 ± 10.1; p < .001), but not plantar flexion (17.5 ± 5.7 vs. 15.4 ± 7.1; p = 0.28) or dorsal flexion (7 ± 5.6 vs. 8.3 ± 4.9; p = 0.3). Complications occurred in six patients (24 %) that led to reoperation: three infections, one lateral impingement, one implant malposition, and one hindfoot alignment disorder. At the last follow-up, implant survival was 96 %, but the probability of survival without reoperation was 78.7 ± 8.5 % at 4 years.

CONCLUSION

TAA revision by arthroplasty is feasible, produces good functional results in the medium term, but has a high risk of complications. The challenge of revision TAA is managing the loss of bone stock and anchoring the new implants.

Does Perioperative Use of Bisphosphonate Affect the Implant Revision Rate of Total Ankle Arthroplasty?

BACKGROUND

It is unknown whether perioperative bisphosphonate (BP) use reduces revision rates in total ankle replacement arthroplasty (TAR) although its effect has been demonstrated to be effective in reducing revision rates in total knee or hip replacement arthroplasty.

METHODS

We reviewed National Health Insurance Service data based on national health insurance service claims data and health care utilization, health screening, sociodemographic variables, medication history, operation codes, and mortality data for 50 million Koreans. From 2002 to 2014, 6391 of 7300 patients who underwent TAR were BP nonusers, whereas 909 patients were BP users. The revision rate according to BP medication and comorbidities was investigated. The Kaplan-Meier estimate and extended Cox proportional hazard model were also used.

RESULTS

The revision rate of TAR was 7.9% for BP users and 9.5% for BP nonusers, which showed no significant difference (P = .251). Implant survival over time decreased constantly. Adjusted hazard ratio for hypertension was 1.242 (P = .017), whereas other comorbidities such as diabetes had no effect on the revision rate of TAR.

CONCLUSION

We found that the perioperative BP use did not reduce the revision rate of TAR. Comorbidities (except hypertension) did not affect the revision rate of TAR. More research regarding various factors affecting the revision of TAR could be warranted.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

How long do ankle arthroplasties last?

Despite the increasing numbers of ankle arthroplasties, there are limited studies on their survival and comparisons between different implants. The primary aim of this study was to determine the failure rates of primary ankle arthroplasties commonly used in the UK. A data linkage study combined National Joint Registry (NJR) data and NHS Digital data. The primary outcome of failure was defined as the removal or exchange of any components of the implanted device. Life tables and Kaplan-Meier survival charts were used to illustrate survivorship. Cox proportional hazards regression models were fitted to compare failure rates between 1 April 2010 and 31 December 2018. Overall, 5,562 primary ankle arthroplasties were recorded in the NJR. Linked data show a one-year survivorship of 98.8% (95% confidence interval (CI) 98.4% to 99.0%), five-year survival in 2,725 patients of 90.2% (95% CI 89.2% to 91.1%), and ten-year survival in 199 patients of 86.2% (95% CI 84.6% to 87.6%). The five-year survival for fixed-bearing implants was 94.3% (95% CI 91.3% to 96.3%) compared to 89.4% (95% CI 88.3% to 90.4%) for mobile-bearing implants. A Cox regression model for all implants with over 100 implantations using the implant with the best survivorship (Infinity) as the reference, only the STAR (hazard ratio (HR) 1.60 (95% CI 0.87 to 2.96)) and INBONE (HR 0.38 (95% CI 0.05 to 2.84)) did not demonstrate worse survival at three and five years. Ankle arthroplasties in the UK have a five-year survival rate of 90.2%, which is lower than recorded on the NJR, because we have shown that approximately one-third of ankle arthroplasty failures are not reported to the NJR. There are statistically significant differences in survival between different implants. Fixed-bearing implants appear to demonstrate higher survivorship than mobile-bearing implants.

Management of Periprosthetic Bone Cysts After Total Ankle Arthroplasty

Modern improvements in total ankle arthroplasty (TAA) have increased the performance of this procedure for treatment of end-stage ankle arthritis. A common finding after TAA is the formation of periprosthetic bone cysts, which can be clinically silent or result in TAA failure. The exact cause of periprosthetic bones cysts has not been established, but major theories are related to osteolysis secondary to implant wear, micromotion, and stress shielding. Treatment can be nonoperative with clinical observation for small, asymptomatic cysts. Large, progressive, and symptomatic cysts often merit surgical treatment with debridement and grafting, revision TAA, or salvage arthrodesis.

Long-term Follow-up of 254 Ceramic Coated Implant (CCI) Evolution Total Ankle Replacements

BACKGROUND

The ceramic coated implant (CCI) Evolution was a third-generation implant design used in approximately 2000 total ankle replacements (TARs) between 2003 and 2016. Because this implant was abandoned, long-term follow-up studies are lacking.

METHODS

All patients undergoing TAR using a CCI prosthesis between 2004 and 2012 were included for analysis. Preoperatively the tibiotalar alignment was measured, and postoperatively the patients were followed up clinically, with radiographs and by questionnaire. The primary outcome was implant survival at 10 years of follow-up. Implant survival was also compared for (1) inflammatory joint disease vs noninflammatory joint disease and (2) preoperative tibiotalar neutral vs varus or valgus alignment. The secondary outcomes were complications, reoperations, and function (assessed by patient-reported outcome measures).

RESULTS

Two hundred fifty-four TARs were performed in 237 patients. Two hundred twelve additional procedures were performed to achieve stable ankles. At 10-year follow-up, the survival was 67.5%, with an average time to revision of 4.5 years. The 10-year survival of the inflammatory joint disease group was 76.8% and of the noninflammatory joint group 63.1% (P = .44). In 248 TARs, the preoperative tibiotalar alignment was measured; (62% neutral, 25% varus, and 13% valgus), these showed 10-year survival rates of 74.7%, 48.2%, and 68.9% respectively (P = .07). The complication rate was 54%; 37% of patients underwent reoperation. At a mean of 8.5 years, postoperative satisfaction scored an average of 7.0 (SD 2.26) on a 0- to 10-point numeric rating scale. The mean Foot and Ankle Ability Measure sports subscore was 24.7, the mean Foot and Ankle Outcome Score (FAOS) sports subscore was 42.8, and the mean 36-Item Short Form Health Survey score was 40.0. Regarding daily activities, the mean FAOS was 81.0.

CONCLUSION

This is currently the sole study reporting the long-term results of the CCI prosthesis. The survival and functional outcomes were inferior to other third-generation mobile-bearing ankle implants.